Lecture 17: Workshop neuropsychological assessment to exclude neurological causes of affective disturbance

Question 1

What are the key features of executive “frontal” functions

Answer 1

Executive frontal functions are required for any tasks that need active processing

• Internal generation of concepts –> without frontal function spontaneous behaviour would not occur
• Task switching - set shifting –> without frontal functions the individual would persevere with behaviour

Individuals with impairments to these functions are:

• Left dorsolateral frontal and subcortical lesions
• Severe psychiatric disorders –> altered attention due to symptoms?
• Some patients may have even in remission

Question 2

Name some passive & active tasks neuropsychological tasks

Answer 2

Passive

• Recognition memory
• Simple visuospatial - copy circle
• Naming pictures
• Matching picture to word for comprehension

Middling

• Complex visuo-spatial –> copy cube
• Short-term memory (repeat digit list)

Active

• Working memory –> serial subtraction
• Recall recent memory –> sentence recently learned
• Word fluency –> as many words beginning with letter
• Trail making - 1-A-2-B –> set-shifting task

Question 3

Outline the cut offs for the ACE-III

Answer 3

< 88 –> 94% sensitivity, 89% specificity
< 82 –> 84% specificity, 100% sensitivity

< 74 –> Dr Larner at Walton advised

Note a lower score may be used for lower IQ backgrounds given that the ACE-III has words which aren’t always easily understood (nautical or marsupial)

Question 4

What symptom may be 1st to present in Alzheimer’s dementia?

Answer 4

Delayed recall

A good test vs affective disorders

• Immediate recall often intact in Alzheimer’s initially
• Patients with affective disorders may lack immediate recall given attention

Question 5

Name some neuroanatomical abnormalities that may be present in alzheimer’s dementia?

Answer 5

Later stages bilaterally

Decreased grey-matter volume in:

• Parieto-temporal
• Medial temporal
• Posterior cingulate/precuneus

Question 6

For Alzheimer’s Dementia outline the

• Lead-symptom
• Time course
• Clinical criteria for dementia (DSM)
• Detailed neuropsychological tests
• Brain CT
• Blood tests

Answer 6

Lead symptom –> impairment of recent memory
Time course –> slowly progressive

• Clinical criteria for dementia –> met, impairment to ADLs and functioning
• Detailed neuropsychological tests in dementia demonstrate poor delayed verbal and nonverbal recall
• Brain CT may show atrophy (larger ventricles, sulci and small hippocampal volumes) but is needed to exclude normal pressure hyrdrocephalus, severe white-matter damage, tumour or stroke
• Bloods are normal

Question 7

Using the template for Alzheimer’s dementia (lead symptom, time course etc) what are the features of mild cognitive impairment

Answer 7

• Impaired recent memory
• Slow progressive time course
• DSM criteria for dementia not met –> lack of impairment to regular life ADLS
• Neuropsychological tests –> mild impairment to delayed recall (verbal/non-verbal) - defined as up to or under 1 SD for age/education adjusted
• CT head and bloods normal (or normal or mild cerebrovascular changes)
• No affective disorder symptoms met

Question 8

Define the key features of a non-organic affective disorder causing cognitive impairment

Answer 8

Lead symptom –> recent memory of routine events impaired

Slow progressing or stable course

Criteria for dementia not met - while impairment to ADLs or functioning this is due to affective symptoms not cognitive component

Neuropsychological tests - relatively intact delayed/verbal recall - no selective impairment for delayed vs immediate, normal figure drawing, normal visuo-spatial tasks, naming capacity is normal. Max impairment is up to 1 SD for education/age adjusted

CT head - normal or mild white matter changes

Bloods normal

Affective disorder criteria are met

Question 9

How will neuropsychological tests present in the behavioural variant of frontotemporal dementia?

Answer 9

May be normal

Main symptoms are behaviour changes (Lund-Manchester Criteria)

Cambridge behavioural inventory –> used to identify stereotypical behaviour, abnormal eating patterns or actions which are not socially appropriate

A brain MRI will show frontal and anterior temporal atrophy

Question 10

For semantic dementia or progressive non-fluent aphasia how would a patient perform in neuropsychological testing?

Answer 10

For naming tasks or repetition –> poorly

Figure drawing and nonverbal memory (figure recall) may be normal

Question 11

Which dementia may show anterior temporal atrophy?

Answer 11

Semantic dementia or progressive non-fluent aphasia

In severe cases PET may show diffuse hypometabolism over the left hemisphere

Question 12

How do the Mesulam 1987 criterion define progressive aphasia time course?

Answer 12

Over at least 2 years there is a gradual decline in symptoms with functioning or ADL remaining intact

Note for semantic dementia or progressive non-fluent aphasia the lead symptom is deficits in language or speech rather than recent memory

Question 13

What do CERAD (consortium to establish a registry for alzheimer’s disease) z scores refer to?

Answer 13

z = 1.5 corresponds to 1.5 SD from age/education adjustive norm

Question 14

How may semantic dementia present?

Answer 14

• impairment of language: first word-finding, then word comprehension, and then object recognition impairment

Question 15

Outline the three forms of frontotemporal dementia?

Answer 15

Behavioural variant

• Neuropsychological testing may be normal
• Atrophy to frontal and anterior temporal regions
• Presents with stereotypical/repetitive actions, may have abnormal eating habits –> lead symptom is behavioural change according Lund-Manchester criteria

Semantic dementia:

• Lead symptoms are speech or language difficulty
• Here speech will remain fluent (understandable) but lose understanding of normal words –> vocab decreased
• On neuropsychological testing –> naming will be the main deficits +/- repetition. Drawing and nonverbal memory may be normal
• Anterior temporal atrophy

Progressive non-fluent aphasia:

• Whereas in semantic dementia the speech is clear in progressive non-fluent aphasia the speech is stuttered and there are grammatical areas
• Anterior temporal atrophy

Both of the semantic dementia/progressive non-fluent aphasia may present with abnormal behaviour (stereotypical, abnormal eating habits or socially inappropriate) but the things to look out for are normal memory and impaired naming or repetition

Question 16

How would you assess this case?

Case:

➢ Since 9 months on sick leave (around 60 years old)
➢ kisses, sings to people at work since 3-5 years
➢since about 3 years verbally aggressive, bullies family around, no violence ➢developed obsession for sudoku in the past few years
➢ since about 6 months problems naming and recognizing objects: saying cupboard instead of fridge, not recognizing shoe laces in a box
➢ since about 6 months also forgetfulness for conversations which took place on the same day
➢ slow progression of behavioural and language symptoms
➢ is independent in personal care, goes out on her own without getting lost, was put on sick leave because of behavioural /cognitive abnormalities at work, but no other impairments of activities of daily living

clinical examination:
Language:
Semantic impairments seem mild in conversation, good comprehension and no word finding problems in conversation, fluent speech, no phonemic paraphasias (i.e. mixed up syllables)

Memory :
remembered my name, each time I rang her,
reports her history and medication appropriately without looking at notes

Insight:
Was tense after testing because she had done poorly on naming.
When asked whether she would have felt embarrassed kissing strangers before her illness she said yes. When asked whether she felt an urge to do so, she answered no, she did this to cheer people up, although her supervisors didn’t like it, she doesn’t know why she was put on sick leave, thinks her doctor did this to be on the safe side because of her memory problems.

Psychopathology:
➢ psychomotorically not appearing cheerful, when asked about her mood, neither down nor up, no visual hallucinations, no fluctuations
➢no prior psychiatric history
Medical and Neurological history:
➢neurological examination: normal, no focal neurological symptoms in history
➢ no family history of neurodegenerative diseases

Answer 16

Possible neuropsychological tests:

• Addenbrook
• Mini mental
• Digit span (WAIS)
• Trail making test
• FAS verbal fluency
• Rey complex figure test
• Benton visual retention test
• Raven’s coloured progressive matrices
• Picture naming
• Wort-to-picture matching
• Pyramids and palmtrees test
• Story recall
• Famous face-place test
• Psycholinguistic assessment of language processing

Neuroimaging:
- MRI scan

Inventory:
- Cambridge behavioural inventory

Blood tests